Medical Policy Updates

Notification of Policy Revisions Effective August 18, 2005 (Posted June 16, 2005)

Medical Policy	Revision
Pulmonary Rehabilitation	Specialty Matched Consultant Advisory Panel review on 05/26/2005. Reference added. G codes G0302, G0303, G0304, G0305, G0237, G0238, and G0239 added to Billing/Coding section. When Pulmonary Rehabilitation is Covered section reformatted and verbiage added to include statements of coverage for single courses of PR for COPD, preoperative conditioning for lobar/lung transplants or lung volume reduction surgery. When Pulmonary Rehabilitation is Not Covered section reformatted and verbiage added to include statements of noncoverage for multiple courses of PR, group therapy and a listing of other situations where PR would not be considered medically necessary. Policy Guidelines section expanded to provide an explanation of the expected components of PR. Benefit Application reformatted for policy language consistency. Billing/Coding section reformatted for policy language consistency. Notice given 6/16/2005. Policy effective date 8/18/ 2005.
Sexual Dysfunction Treatment, Male	Specialty Matched Consultant Advisory Panel review 5/24/05. Under "When covered" section, deleted statement before #2 - "In the absence of evidence of organic causes for impotence, documentation of a Nocturnal Penile Tumescence test....." #2.f re: Penile prosthesis - now includes the requirement that results from Nocturnal Penile Tumescence (NPT) and/or rigidity testing (e.g., Rigi-scan) indicate that the erectile dysfunction is organic and not psychogenic in nature; and that the patient has attempted less invasive therapies (a, b, c, d, and/or e) with failure to have an adequate erection. Policy status changed to "Active policy, no longer scheduled for routine literature review." Notice given 6/16/05. Effective date 8/18/05.
Urinary Incontinence, Treatment	Specialty Matched Consultant Advisory Panel review 5/24/05. Section I - Periurethral Injection of Implant Material for the Treatment of Urinary Incontinence; description revised, included biocompatible copolymer implant (e.g., URYX) in description; For "When Covered"- 2.d. "Cross-linked collagen or carbon-coated beads are used as the implantable material." pulled out as a separate sentence so need 1 or 2 and use of listed materials; also added biocompatible copolymers as one of the approved materials; For "When not Covered" added "The use of autologous fat and autologous ear chondrocytes as periurethral bulking agents are considered investigational and are not covered."; For "Policy Guidelines" removed sentence re: "15 ml of paste are injected..." since the procedure is included in the description. Section II - Sacral Nerve Modulation/Stimulation...description of procedure revised to provide additional information; For "When Covered" - changed #2 to indicate that the urinary incontinence conditions listed in #1 should not be related to a neurologic condition; #3 now reads: "Medical records document that the patient has failed at least a 3 month trial of conservative treatment such as behavioral therapy (i.e., diet modification, bladder training, biofeedback, Kegel exercises) and/or pharmacotherapy (i.e., 2 or more anti-cholinergic drugs or a combination of an anti-cholinergic and a tricyclic anti-depressant); #4 is now re: the percutaneous test stimulation. For "When not Covered" #1 - added several examples of conditions "Any conditions other than those listed above including but not limited to the following: stress incontinence, urge incontinence due to a neurologic condition (e.g., detrusor hyperreflexia, multiple sclerosis or spinal cord injury), other types of chronic voiding dysfunction, patients with mechanical urethral obstruction such as benign prostatic hypertrophy, cancer or urethral stricture." Section III - Pelvic Floor Stimulation...added policy guidelines re: investigational status: "Available data are insufficient to determine whether this treatment is as effective as alternatives. Additionally, the treatments lack standardization of delivery. There are minimal data for magnetic stimulation and no randomized trials. There is insufficient medical and scientific evidence to permit the Plan to evaluate the therapeutic value of pelvic floor stimulation as a treatment of urinary incontinence. For further information, please refer to separate policy number MED1263, Investigational (Experimental) Services." Added - Section IV re: Transvaginal Radiofrequency Bladder Neck Suspension for Urinary Stress Incontinence as investigational. Notice given 6/16/05. Effective date 8/18/05.